Independent Contractor Questionnaire

Independent Contractor Questionnaire

Please provide the following background information:

Name: _____________________________

Fictitious business name (if any): ___________________________________

Business address: ___________________________________

Business phone number: ________________ Cell: ____________________

Email address: _______________________

Employer identification number or Social Security number: _________________

Form of business entity (check one):

[ ] Corporation [ ] Partnership [ ] Sole Proprietorship [ ] Limited Liability Company

Please provide the name, address, and dates of service of all companies for which you have performed services as an independent contractor for the past two years. Please do not provide any information you have a duty to keep confidential. ____________________________________________________________

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Workers' compensation carrier and policy number: __________________________

____________________________________________________________

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Describe the training you have received in your specialty.

School attended:

Dates of attendance: Degrees received:

School attended: ___________________________________

Dates of attendance: ________________ Degrees received: ________________

School attended: ___________________________________

Dates of attendance: ________________ Degrees received: ________________

Do you advertise your services? [ ] Yes [ ] No

If you don't advertise, how do you market your services? ____________________________________________________________

____________________________________________________________

________________________

Describe the business expenses you have paid in the past two years, including office or workplace rental, materials and equipment expenses, telephone, and other expenses: ____________________________________________________________

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